In the October 2015 issue of the Journal, Pepine et al. (1) presented the current concepts on nonobstructive coronary artery disease as an origin of ischemic heart disease and associated adverse outcomes among women. The authors emphasized the need for further evaluation to clarify the emerging paradigm of nonobstructive coronary artery disease especially in women to define proper short-term and long-term treatment. To expand this point further, we would like to add our novel project to increase the level of knowledge about the dilemma of cardiac syndrome X (CSX) (2,3), which is currently deficient.

In our study, we assessed the prevalence of migraine headache, according to the International Classification of Headache Disorders, in 3 groups: a CSX group (n = 50), a coronary artery disease group (n = 50), and a healthy group (n = 50) using a well-designed prospective study. The prevalence of migraine was 60% in CSX patients, 16% in the coronary artery disease group and 22% in the healthy group (p < 0.0001). The frequency of migraine headache in women with CSX was 70.4% and in men was 52.2%. Our study concluded that CSX may presumably be a manifestation of migraine as another migraine equivalent.

The connection between CSX and migraine headache has not yet been fully addressed. One of the suggested mechanisms in relation to migraine and angina pectoris is vasospasm, as has been seen previously in the coronary and cerebral arteries of patients with migraine headache (4,5). This occurrence can be clarified using functional brain imaging during the symptomatic phase of CSX to reveal cerebral perfusion changes similar to the migraine complex. Endothelial disturbance and different reactions to mediators, such as endothelin, is another probable theory that connects CSX and migraine headache (3). The third presumable mechanism causing chest pain in migraine patients is mitochondrial dysfunction. It may occur in the myocardial tissue of patients with migraine headache, which may eventually present with a clinical manifestation similar to CSX (2,5). However, there are many debates about the connection of CSX and migraine, and future studies are needed.

After the ongoing evidence on the multifaceted pathophysiology of CSX, it became even more clear that there is a need for a pragmatic approach to education and training of medical practitioners in the management of patients, especially in refractory patients using the current treatment.

Footnotes

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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